Characteristics and predictors of death among hospitalized HIV-infected patients in a low HIV prevalence country: Bangladesh

The estimation of long and short term survival time and associated factors of HIV patients using mixture cure rate models

BACKGROUND

HIV is one of the deadliest epidemics and one of the most critical global public health issues. Some are susceptible to die among people living with HIV and some survive longer. The aim of the present study is to use mixture cure models to estimate factors affecting short- and long-term survival of HIV patients.

METHODS

The total sample size was 2170 HIV-infected people referred to the disease counseling centers in Kermanshah Province, in the west of Iran, from 1998 to 2019. A Semiparametric PH mixture cure model and a mixture cure frailty model were fitted to the data. Also, a comparison between these two models was performed.

RESULTS

Based on the results of the mixture cure frailty model, antiretroviral therapy, tuberculosis infection, history of imprisonment, and mode of HIV transmission influenced short-term survival time (p-value < 0.05). On the other hand, prison history, antiretroviral therapy, mode of HIV transmission, age, marital status, gender, and education were significantly associated with long-term survival (p-value < 0.05). The concordance criteria (K-index) value for the mixture cure frailty model was 0.65 whereas for the semiparametric PH mixture cure model was 0.62.

CONCLUSION

This study showed that the frailty mixture cure models is more suitable in the situation where the studied population consisted of two groups, susceptible and non-susceptible to the event of death. The people with a prison history, who received ART treatment, and contracted HIV through injection drug users survive longer. Health professionals should pay more attention to these findings in HIV prevention and treatment.

Effects of Undernutrition and Predictors on the Survival Status of HIV-Positive Children after Started Antiretroviral Therapy (ART) in Northwest Ethiopia

Malnutrition and human immunodeficiency virus/acquired immunodeficiency syndrome have complex and multidirectional relationships. Ethiopia is one of the countries hardest hit by the HIV epidemic as well as malnutrition. This study was aimed at assessing the effects of undernutrition on the survival status of HIV-positive children who received HIV/AIDS care in Northwest Ethiopia. Materials and Methods. A facility-based retrospective follow-up was conducted from January 1, 2009, to December 31, 2020. The data was entered into EpiData version 4.2.0. Then, the entered data was exported to STATA 14 software for further analysis, and the Kaplan-Meier survival curve was used to estimate survival time after the initiation of ART. The Bivariable and multivariable Cox regression analyses were conducted to identify predictors of mortality associated with undernutrition. Results. The mean (±SD) age of participant children was found 118.4 (±38.24) months. The overall mortality rate in this study was determined as 5.4 per 100 child-years (95% CI: 3.6, 5.8). Children with CD4 cell counts below the threshold [AHR = 1.6; 95% CI (1.19, 7.85)], advanced WHO clinical stages (III and IV) HIV [AHR = 4.5; 95% CI (2.80, 8.40)], and being severe stunting at the beginning [AHR = 2.9; 95% CI (1.80, 6.40)] were significantly associated with mortality of HIV-positive children. Conclusion. The findings of the current study indicated that HIV-positive children on ART had a high rate of mortality. Baseline undernutrition has the mortality of children who had CD4 counts below a threshold, advanced WHO HIV clinical staging (III and IV), and being severe stunting (HAZ ≤ −3 Z score) which were found to be independent predictors for mortality of undernourished HIV.

Invasive Fungal Infections in Under-Five Diarrheal Children: Experience from an Urban Diarrheal Disease Hospital

Invasive fungal infections (IFIs) are opportunistic, especially in immunocompromised and hospitalized patients. Children with IFIs are more vulnerable to a fatal outcome. For early diagnosis and treatment, knowledge of the spectrum and frequency of IFIs among children is prerequisite. In this prospective observational study, we enrolled 168 children of 2–59 months old of either sex from March 2018 to December 2019 admitted to the Dhaka hospital, icddr,b. Study participants with suspected IFIs were with or without severe acute malnutrition (SAM) along with sepsis/pneumonia and fulfilled any of the following criteria: (i) failure to respond to injectable antibiotics, (ii) development of a late-onset hospital-acquired infection, (iii) needed ICU care for >7 days, (iv) took steroids/antibiotics for >2 weeks before hospitalization, and (v) developed thrush after taking injectable antibiotics. The comparison group included non-SAM (weight-for-length Z score ≥ −2) children with diarrhea and fever <3 days in the absence of co-morbidity. We performed real-time PCR, ELISA, and blood culture for the detection of fungal pathogen. Study group children with SAM, positive ELISA and PCR considered to have a IFIs. In the study group, 15/138 (10.87%) children had IFIs. Among IFIs, invasive candidiasis, aspergillosis, histoplasmosis detected in 6 (4.53%), 11 (7.97%), and 1 (0.72%) children, respectively, and (3/15 [2.17%]) children had both candidiasis and aspergillosis. Children with IFIs more often encountered septic shock (26.7% vs. 4.9%; p = 0.013) and had a higher death rate (46.7% vs. 8.9%; p < 0.001) than those without IFIs. IFIs were independently associated with female sex (OR = 3.48; 95% CI = 1.05, 11.55; p = 0.042) after adjusting for potential confounders. Our findings thus implicate that, malnourished children with septic shock require targeted screening for the early diagnosis and prompt management of IFIs that may help to reduce IFIs related deaths.

Independent Risk Factors for Deaths due to AIDS in Chongqing, China: Does Age Matter?

Background: People living with HIV (PLWH) are aging worldwide, and different management strategies may be required for older and younger PLWH. However, demographic characteristics, illness distribution, mortality, and independent risk factors in the PLWH population in China are not yet fully understood, especially in patients aged 50 years or older.

Methods: We conducted a retrospective analysis of 4445 HIV-positive Chinese inpatients in Chongqing, China.

Results: The mortality rate in patients 50 years or older (the older group) was significantly higher than that in those under 50 years (the younger group) (p < 0.001). In the younger group, independent risk factors for death included: nadir CD4+ T-cell counts <200 cells/μL, not owning medical healthcare insurance, not being on cART, injection drug use, and having one of the following comorbidities: Pneumocystis pneumonia, cryptococcal meningitis, AIDS malignancy, non-AIDS malignancy, and kidney disease. In the older group, independent predictors of death included: being urban residents, nadir CD4+ T-cell counts <200 cells/μL, not being on cART, and having comorbidities such as Pneumocystis pneumonia, hepatitis C, talaromycosis, non-AIDS malignancy, and kidney disease.

Conclusions: Demographic characteristics, illness distribution, mortality, and independent risk factors for death in HIV-positive patients differ between the older group and the younger group, indicating that a changing suite of medical and allied support services may be required the for management of older PLWH.

Mortality rate among HIV-positive children on ART in Northwest Ethiopia: a historical cohort study

Background

Though highly active antiretroviral therapy (HAART) has been available for more than a decade in Ethiopia, information regarding mortality rates of human immunodeficiency virus (HIV)-positive children after antiretroviral therapy antiretroviral therapy (ART) initiation is very scarce. Thus, this study intends to determine the predictors of mortality among HIV-positive children receiving ART in Amhara Region.

Methods

A multicenter facility-based historical cohort study was conducted in 538 HIV-positive children on ART from January 2012 to February 2017. We employed a standardized data extraction tool, adapted from ART entry and follow-up forms. Descriptive analyses were summarized using the Kaplan-Meier survival curve and log rank test. Then, the Cox-proportional hazard regression model was employed to estimate the hazard of death up to five-years after ART initiation. Variables with p-values ≤0.25 in bivariable analysis were candidates to the multivariable analysis. Finally, variables with p-values < 0.05 were considered as significant variables.

Results

The cohort contributed a total follow-up time of 14,600 child-months, with an overall mortality rate of 3.2 (95% CI: 2.3, 4.3) per 100 child-years. This study also indicated that HIV-infected children presenting with opportunistic infections (OIs) (AHR: 2.5, 95% CI: 1.04, 5.9), anemia (AHR: 3.1, 95% CI: 1.4, 6.7), severe immunodeficiency (AHR: 4.4, 95% CI: 1.7, 11.7), severe stunting (AHR: 3.3, 95% CI: 1.4, 8.0), severe wasting (AHR: 3.1, 95% CI: 1.3, 7.3), and advanced disease staging (III and IV) (AHR: 3.0, 95% CI: 1.2, 7.1) were at higher risk of mortality.

Conclusion

A higher rate of mortality was observed in our study as compared to previous Ethiopian studies. HIV-positive children presenting with anemia, OIs, severe immunodeficiency, advanced disease staging (III and IV), severe stunting, and severe wasting were at higher risk of mortality.

Histoplasmosis: An Emerging or Neglected Disease in Bangladesh? A Systematic Review

Histoplasmosis is uncommon in many parts of the world, including Bangladesh, where, in recent years, cases are increasingly reported. We sought to describe the sociodemographic characteristics, clinical presentation, investigations, treatment, and outcome of histoplasmosis in Bangladesh. We conducted a retrospective data review of published literature from 1962 to 2017, containing information on histoplasmosis in and/or from Bangladesh. Unpublished, well-documented histoplasmosis cases were also included. A total of 26 male patients aged 8–75 years, with a diagnosis of histoplasmosis were included; nine were farmers, seven had diabetes, one was a renal transplant recipient, and four had HIV/AIDS. Fever (n = 20), weight loss (n = 17), anemia (n = 15), lymphadenopathy (n = 9), and hepatosplenomegaly (n = 7) were common. Eleven patients had bilateral adrenal enlargement. Diagnosis was confirmed by histo/cytopathology from skin (n = 1), oropharyngeal ulcers (n = 8), lymph nodes (n = 3), adrenal glands (n = 11), paravertebral soft tissue (n = 2), and bone marrow (n = 4). Cultures of representative samples and antibodies were detected in three and two cases, respectively. Twenty-two patients had disseminated histoplasmosis and four patients had localized oropharyngeal disease. Nine patients were prescribed anti-tuberculosis drugs empirically before establishing the diagnosis of histoplasmosis. Treatment consisted of amphotericin B and itraconazole. Six patients died in hospital, 14 patients recovered with relapse in two cases, and the outcome of the other patients could not be ascertained. Histoplasmosis is thought to be endemic in Bangladesh, but few cases are reported to date, which may be due to many asymptomatic, undiagnosed, misdiagnosed, or under-reported cases. Histoplasmosis should be considered as a differential in appropriate clinical scenarios.

A Clinical scoring model to predict mortality in HIV/TB co-infected patients at end stage of AIDS in China: An observational cohort study

We construct and validate a non-invasive clinical scoring model to predict mortality in HIV/TB patients at end stage of AIDS in China. There were 1,007 HIV/TB patients admitted to Beijing Ditan Hospital from August 2009 to January 2018 included in this study, who were randomly assigned to form derivation cohort and validation cohort. A clinical scoring model was developed based on predictors associated with mortality identified with Cox proportional hazard models. The discrimination and accuracy of model were further validated using the area under the ROC curves. The derivation and validation cohort consisted of 807 and 200 patients in 8:2 ratio, respectively. In derivation cohort, anemia (HGB < 90g/L), tuberculous meningitis, severe pneumonia, hypoalbuminemia, unexplained infections or space-occupying lesions, and malignancies remained independent risk factors of mortality in HIV/TB co-infected patients, and included in this clinical scoring model. The model indicated good discrimination, including AUC = 0.858 (95% CI: 0.782-0.943) in the derivation cohort, and AUC = 0.867 (95% CI: 0.832-0.902) in validation cohort, respectively. The predicted scores were categorized into two groups to predict the mortality: low-risk (0-2 points with mortality with 3.6-9.1%) and high-risk (4-16 points with mortality with 26.42-74.62%), in which 54.55% and 74.62% of patients with score of 5 to 11 and 12-16 were died among high-risk group. Kaplan-Meier curve indicated a significant difference in the cumulative mortality in the two groups by log-rank test (p < 0.001). A clinical scoring model to assess the prognosis in HIV/TB patients at end stage of AIDS was constructed based on simple laboratory and clinical features available at admission, which may be an easy-to-use tool for physicians to evaluate the prognosis and treatment outcome in HIV/TB co-infected patients. The model was also applicable for predicting the death of end-stage HIV/TB patients within a 12 months period after discharge.

Estimation of the Burden of Serious Human Fungal Infections in Malaysia

Fungal infections (mycoses) are likely to occur more frequently as ever-increasingly sophisticated healthcare systems create greater risk factors. There is a paucity of systematic data on the incidence and prevalence of human fungal infections in Malaysia. We conducted a comprehensive study to estimate the burden of serious fungal infections in Malaysia. Our study showed that recurrent vaginal candidiasis (>4 episodes/year) was the most common of all cases with a diagnosis of candidiasis (n = 501,138). Oesophageal candidiasis (n = 5850) was most predominant among individuals with HIV infection. Candidemia incidence (n = 1533) was estimated in hospitalized individuals, some receiving treatment for cancer (n = 1073), and was detected also in individuals admitted to intensive care units (ICU) (n = 460). In adults with asthma, allergic bronchopulmonary aspergillosis (ABPA) was the second most common respiratory mycoses noticed (n = 30,062) along with severe asthma with fungal sensitization (n = 39,628). Invasive aspergillosis was estimated in 184 cases undergoing anti-cancer treatment and 834 ICU cases. Cryptococcal meningitis was diagnosed in 700 subjects with HIV/AIDS and Pneumocystis jirovecii pneumonitis (PCP) in 1286 subjects with underlying HIV disease. The present study indicates that at least 590,214 of the Malaysian population (1.93%) is affected by a serious fungal infection annually. This problem is serious enough to warrant the further epidemiological studies to estimate the burden of human fungal infections in Malaysia.

Effects of undernutrition on survival of human immunodeficiency virus positive children on antiretroviral therapy

Background

The relationship between undernutrition and HIV is bidirectional, ultimately contributing to quality of life and survival of affected individuals. Ethiopia is a sub-Saharan nation influenced by both undernutrition and HIV. In Ethiopia, although individuals are often dually impacted, the effect of undernutrition on the survival of HIV positive children on anti-retroviral therapy (ART) has not been well investigated. Therefore, this study assessed the effect of undernutrition on survival rates of HIV positive children on ART in Amhara Regional State of Ethiopia.

Methods

An institution-based retrospective cohort study was conducted among 390 HIV positive children on ART from the 1st of January, 2012 to the 28th of February, 2017 in Amhara Regional State Referral Hospitals. A simple random sampling technique was used to select the study participants. Data were extracted by reviewing patients’ ART intake and follow-up forms. Data were entered into Epi-Data Version 3.1, and analysis was done using STATA Version 13. The Kaplan-Meier survival curve was used to estimate the cumulative survival time of the sample. Log rank tests were employed to compare the survival time between different categories of explanatory variables. Bivariable and multivariable Cox proportional hazards models were fitted to identify predictors of mortality.

Results

Among the 390 records included in the final analysis, 9.7% of the individuals died within the follow-up period. In this study, the overall mortality rate was found to be 4.4 per 100 child-years (95% CI: 3.2, 6.0) while undernourished children had a lower survival time than well-nourished children. Low hemoglobin level (AHR: 3.2, 95% CI: 1.4, 7.4), CD4 cell count or percent below the threshold (AHR: 5.2, 95% CI: 1.9, 14.1), severe stunting (AHR: 3.9, 95% CI: 1.7, 9.4), severe wasting (AHR: 3.0, 95% CI: 1.3, 6.9) and advanced disease stage (III and IV) (AHR: 2.6, 95% CI: 1.1, 6.6) were found to be predictors of mortality.

Conclusion

There was a high rate of mortality. A significant difference was observed in the survival rate of undernourished and well-nourished children. Low hemoglobin level, CD4 count or percent below the threshold, severe wasting, severe stunting, and advanced disease stage were found to be predictors of mortality.

Low Lymphocyte Proportion in Bronchoalveolar Lavage Fluid as a Risk Factor Associated with the Change from Trimethoprim/sulfamethoxazole used as First-Line Treatment for Pneumocystis jirovecii Pneumonia

Background

Trimethoprim/sufamethoxazole (TMP/SMX) is the recommended treatment for Pneumocystis jirovecii pneumonia (PCP). However, the efficacy and the safety of alternative salvage treatments are less guarauteed especially when patient experiences treatment failure and/or an adverse drug reactions (ADR). The purpose of this study is to recognize potential risk factors imitating successful treatment with TMP/SMX among PCP patients.

Materials and Methods

Ninety one adult patients diagnosed with PCP were included after searching electronical medical records from January 2013 through July 2015 at Asan Medical Center Seoul, Korea. We compared clinical characteristics and laboratory findings including bronchoalveolar lavage (BAL) fluid analysis in patients who experienced TMP/SMX treatment failure or ADR (the case group) versus those who did not (the control group).

Results

Among the enrolled PCP patients, 39 (42.9%) required salvage treatment owing to either treatment failure (28, 28.6%) and/or ADR (17, 18.7%). The BAL lymphocyte percentage (25% [IQR, 8–40%] vs. 47% [IQR, 15–62%]; P = 0.005) was lower in the case group. Diabetes mellitus (adjusted odds ratio [aOR] 4.98, 95% confidence interval [95% CI] 1.20–18.58), glomerular filtration rate ≤50 mL/min (aOR 4.48, 95% CI 1.08–18.66), and BAL lymphocyte percentage ≤45% (aOR 9.25, 95% CI 2.47–34.58) were independently associated with the case group in multivariate analysis.

Conclusion

This study suggests that BAL lymphocyte count may play some role during PCP treatment. Further studies should be followed to reveal what the role of BAL lymphocyte is in the PCP treatment.

Minimizing fungal disease deaths will allow the UNAIDS target of reducing annual AIDS deaths below 500 000 by 2020 to be realized

Deaths from AIDS (1 500 000 in 2013) have been falling more slowly than anticipated with improved access to antiretroviral therapy. Opportunistic infections account for most AIDS-related mortality, with a median age of death in the mid-30s. About 360 000 (24%) of AIDS deaths are attributed to tuberculosis. Fungal infections deaths in AIDS were estimated at more than 700 000 deaths (47%) annually. Rapid diagnostic tools and antifungal agents are available for these diseases and would likely have a major impact in reducing deaths. Scenarios for reduction of avoidable deaths were constructed based on published outcomes of the real-life impact of diagnostics and generic antifungal drugs to 2020. Annual deaths could fall for cryptococcal disease by 70 000, Pneumocystis pneumonia by 162 500, disseminated histoplasmosis by 48 000 and chronic pulmonary aspergillosis by 33 500, with approximately 60% coverage of diagnostics and antifungal agents; a total of >1 000 000 lives saved over 5 years. If factored in with the 90–90–90 campaign rollout and its effect, AIDS deaths could fall to 426 000 annually by 2020, with further reductions possible with increased coverage. Action could and should be taken by donors, national and international public health agencies, NGOs and governments to achieve the UNAIDS mortality reduction target, by scaling up capability to detect and treat fungal disease in AIDS.

This article is part of the themed issue ‘Tackling emerging fungal threats to animal health, food security and ecosystem resilience’.

Burden of serious fungal infections in Bangladesh

In Bangladesh there are several published papers on superficial mycoses. Deep mycoses are also recognized as an important emerging problem. Here, we estimate the annual incidence and prevalence of serious fungal infections in Bangladesh. Demographic data were obtained from world population reports and the data on TB and HIV extracted from the online publications on tuberculosis in Bangladesh and Asia Pacific research statistical data information resources AIDS Data HUB. All the published papers on fungal infections in Bangladesh were identified through extensive search of literature. We estimated the number of affected people from populations at risk and local epidemiological data. Bangladesh has a population of ∼162.6 million, 31% children and only 6% over the age of 60 years. The pulmonary TB caseload reported in 2014 was 119,520, and we estimate a prevalence of 30,178 people with chronic pulmonary aspergillosis, 80% attributable to TB. An anticipated 90,262 and 119,146 patients have allergic bronchopulmonary aspergillosis or severe asthma with fungal sensitization. Only 8,000 people are estimated to be HIV-infected, of whom 2900 are not on ART with a CD4 count <350 μL, Pneumocystis pneumonia and cryptococcal meningitis being rare. Superficial mycoses are very common with Trichophyton rubrum as the predominant etiological agent (80.6%). Numerous cases of mycotic keratitis have been reported from several parts of Bangladesh. Candida bloodstream infection was estimated based on a 5 per 100,000 rate (8100 cases) and invasive aspergillosis based primarily on leukemia and COPD rates, at 5166 cases. Histoplasmosis was documented in 16 cases mostly with disseminated disease and presumed in 21 with HIV infection. This study constitutes the first attempt to estimate the burden of several types of serious fungal infections in Bangladesh.

Spectrum of Opportunistic Infections and Risk Factors for In-Hospital Mortality of Admitted AIDS Patients in Shanghai

To investigate the frequency and the spectrum of major opportunistic infections (OIs), evaluate the major clinical factors associated with each specific OI, and identify the risk factors for in-hospital death among HIV patients in East China.A retrospective cohort study was made including all the HIV-infected patients who were admitted for the first time to the Shanghai Public Health Clinical Center during June 1, 2013 to June 1, 2015. The demographic and clinical data were collected. Comparison of continuous variables was analyzed by one-way ANOVA and rank sum test. Person χ test and Fisher exact test were applied to analyze the categorical variables. A Cox proportional hazards regression model was used to determine the risk for the occurrence of in-hospital death.In total, 920 patients were enrolled with age of 41.59 ± 13.36 years and 91% male. Median CD4 was 34 (IQR, 13-94) cells/μL. Among these patients, 94.7% acquired OIs while the rest developed malignancies. Pneumocystis pneumonia and bacterial coinfection (42.1%) was found to be the most common OIs, followed by tuberculosis (31.4%), CMV (20.9%), Cryptococcosis (9.0%), and MAC infection (5.2%). Of the above 5 major OIs, CMV-infected patients had the lowest median CD4 cell count 22.50 (IQR, 7.50-82.00) while the patients with tuberculosis infection had the highest count 61.00 (IQR, 27.00-176.00). In-hospital death rate was 4.2 per 100 person-years among these patients. Of note, admitted patients with 2 types of OIs (2.20, 95% CI 1.39-3.48) and those patients who were 40-year old or older (1.75, 95% CI 1.10-2.78) had a higher risk of such death.Pneumocystis pneumonia and tuberculosis were still the leading causes for the admission of HIV-infected patients in East China, and these patients tended to have very low CD4 cell counts. It is believed that expanding the HIV screening test and pushing the infected ones get ART earlier is required for generating a more successful HIV management strategy.

Profile of an HIV Testing and Counseling Unit in Bangladesh: Majority of New Diagnoses among Returning Migrant Workers and Spouses

Introduction

Analysis of data from HIV testing and counseling (HTC) services provides an opportunity to identify important populations for targeting of HIV prevention efforts. Our primary aim was to describe the demographics of clients presenting to HTC in Bangladesh, a low HIV prevalence country. Our secondary aim was to determine the risk factors for HIV positivity among returning migrant workers who were tested.

Methods

We performed a cross-sectional study of data collected between 2002 and 2010 from the first HTC service established in Bangladesh, located in three large cities.

Results

8973 individuals attended HTC services, with 558 (6.2%) of clients testing positive for HIV, including 33 children. The majority of those who tested positive were aged 25–44 (71%), male (70%), and married (68%). Key populations considered at increased risk of HIV, such as female sex workers, people who inject drugs, and males who have sex with males accounted for only 11% of adults who tested positive. Notably, 75% of adults testing positive had a history of migrant work or was the spouse of a migrant worker. In multivariable logistic regression of those with a migrant work history presenting for HTC, we found rural residence, working in the Middle East, and longer duration of migrant work to be independently associated with testing positive, and female gender and higher level of education to be negatively associated.

Conclusions

These data suggest that in Bangladesh, in addition to targeting traditional key populations, HIV prevention efforts should also focus on migrant workers and their spouses.

A qualitative exploration of parental experiences of stigma while living with HIV in Bangladesh

With much of the focus on the "risk" groups, families have often been less studied in HIV research. Further, because of a focus on the aetiology and epidemiology of HIV, the social impacts associated with HIV on families and neighbours are sometimes overlooked. This study examined parental experiences of stigma and discrimination while living with HIV within a family context in Bangladesh. A qualitative research design using a grounded theory approach was used for this research. Data was collected through in-depth interviews with 19 HIV-positive parents, recruited with the support of two self-help groups of HIV-positive people, in two settings namely Khulna and Dhaka in Bangladesh. The findings indicate that HIV-positive parents held the view that they continue to experience significant stigma and their narratives clearly show how this affected them and their children. A range of informal practices were enacted in everyday contexts by extended family and community members to identify, demarcate and limit the social interaction of HIV-positive parents. Parents highlighted a number of factors including negative thoughts and behaviours, rejection, isolation and derogatory remarks as manifestations of stigma and discrimination, impacting upon them and their children because of their association with HIV.